No single HIV prevention method can end AIDS: Combination prevention is key

As HIV prevention needs and contexts vary, it is important to expand the range of effective prevention options that people can use. Archbishop Desmond Tutu said in a video link at the first-ever international conference on all HIV-related biomedical prevention research, that “No single method of prevention can end this epidemic on its own." That is why conferences on microbicides and vaccines merged to provide one single global platform to deliberate on a spectrum of biomedical prevention research for HIV. HIV Research for Prevention (HIVR4P) is being held in Cape Town, South Africa. Professor Helen Rees, Executive Director, Wits Reproductive Health and HIV Institute and HIV R4P conference co-chair, explained the value of breaking the walls between vertical conferences on specific biomedical prevention options such as microbicide and vaccine. “There are commonalities. There are issues which HIV vaccine basic scientists might be looking at which may also be very important for microbicide or Pre-Exposure Prophylaxis (PrEP) scientists too and vice versa.” Challenges of adherence to drugs-under research or ways to modify trial design to fast track the process are also common across the sector of HIV prevention research. Mechanisms in which socio-behavioural research informs the basic science are also a priority across the board. By organizing one conference on biomedical prevention research for HIV, “we were able to look at these commonalities together while not losing the uniqueness of these specific fields” said Rees.

Synergy between different streams of HIV prevention is crucial so that new infection rate dips faster than ever before to end AIDS. South African Minister for Science and Technology Mrs GNM Pandor said at HIVR4P that more people get newly infected with HIV than those people living with HIV (PLHIV) who are put on antiretroviral therapy (ART). “There are 2.4 million PLHIV on ART in South Africa” said Pandor. It is important to underline that there are estimated 6.3 million PLHIV in South Africa as per latest data from UNAIDS. The road to scale up treatment for everyone is still long. Alongside scaling up ART to every PLHIV and other measures, we surely need to scale up effective prevention services radically.

“Increase in ART has resulted in reduction in number of people dying as result of HIV infection and significant reduction in mother to child transmission of HIV. We remain many years away from eliminating HIV. We are not investing in social sciences enough. We have to get the behavioural aspects right in HIV prevention research” said Pandor. “As we know, No single method of prevention can end this epidemic on its own, our focus remains in offering a package of HIV prevention together. We need to respond to epidemic in more comprehensive manner than merely offering individual interventions.”

Developing safe and effective HIV prevention tools are critically important but not enough. “We need to move research outcomes into clinical practice, which continues to remain a challenge” said Pandor. She was right on spot. Female condoms got approved by US FDA in 1993 but lot more needs to be done to roll them out to every woman in need for protection against unintended pregnancy and/or sexually transmitted infections (STIs) including HIV. Undoubtedly more work needs to be done to ensure there is no delay in taking research outcomes forward to yield public health benefits.

Dr Anthony Fauci, Director, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), USA, addressed HIVR4P via a video link. He said that HIVR4P is rightly addressing all biomedical prevention options at one forum. He said that non-vaccine prevention options and vaccine both are required to stem the pandemic.

Dr Fauci underlined that non-vaccine prevention options need to be taken regularly but vaccines once given does not have those adherence issues. “Non-vaccine prevention options are highly effective but requires continual adherence, whereas vaccine are often modestly effective but durable, and does not have continual adherence issues” said Fauci.

“Foundation of HIV prevention is infact HIV testing” said Fauci. HIV testing connects to two streams: if the test is positive then person should be connected to care continuum and if negative, then to prevention continuum. He said that there are gaps in care continuum and we must find ways to fill these gaps. Referring to prevention continuum, Fauci said that if the test is negative then the person is encouraged for counselling and risk stratification, and provided tailored prevention services from the ‘prevention toolbox’.

Fauci was referring to a range of HIV prevention options that have been proven to work effectively such as: HIV testing and counselling, treatment as prevention, voluntary medical male circumcision (VMMC), treatment of STIs, rectal and vaginal microbicides (both are currently under research), prevention or treatment of drug and alcohol use, provision of clean needles and syringes, education, behaviour modification, male and female condoms, blood supply screening, antiretroviral drugs for prevention of mother to child transmission of HIV (PMTCT), Post-Exposure Prophylaxis (PEP), and Pre-Exposure Prophylaxis (PrEP). Vaccines will also get added to this ‘toolbox’ once proven to be safe and effective in ongoing research studies, said Fauci. There is no effective HIV vaccine available today. Yet a safe and effective vaccine is critical to the control of HIV globally.

He also stressed to fashion combination prevention for ‘hotspots’ of HIV infection. He gave an example of Lake Victoria area in Kenya which has HIV rates comparable to places in Africa with highest HIV prevalence. This area is also known to have low male circumcision rates and unsafe sex work associated with fishing community is also reported. But rest of the Kenya does not have that high HIV rates. Combination prevention needs to be tailored in unique contexts and realities and if we do so, we could prevent “600,000 new HIV infections by 2030” said Fauci.